Training Agenda August 17th 2010 Baton Rouge

Pathways Housing First!PROGRAM PHILOSOPHY AND PRACTICE Sam Tsemberis, PhDCEO Pathways National

Wellington, NZ October 21, 2015

1AgendaHomelessness Cross Cultural PerspectiveHousing First: Why the Need for a Different Approach? Housing and Support ServicesPhilosophy and Program practice Intensive Support TeamsProgram Fidelity and EffectivenessQ & A Discussion

2Gini Coefficient:Income Disparity and Social Services

P. Toro, Income Disparity and Social Services.3Cross Cultural Similarities and DifferencesWide variations in social welfare systemsDefinition of homeless varies Advocates, Policy Makers and researchersRange from Rough Sleepers or literally Homeless to stably housed

Single Adults more men, higher rates of SA, Trauma, MIOver representation of groups who are discriminated againstTypically refers to 3 major groups- Single Adults, families and Youth 4HomelessDrop-In/ShelterTransitional housingPermanent housingLevel of independenceBased on traditional but unwarranted Treatment assumptions PLUS Negative attributions toward the poor Traditional Services ApproachLinear Residential Continuum of Care55

Staircase: Unrealistic Expectations and a significant number cannot succeed6Why the chronically homeless?Repeatedly failed by existing systemsOverwhelm existing systems to a disproportionate degreeWell known to the communityConsensus among multiple stakeholdersOpportunity to improve the overall system

7Who is served by Housing First programs?Chronic & Episodically Homeless640 from8Trajectories for those who remainchronically homeless Institutional Circuit10% of the population use 50% of system resources99Talk through the institutional circuitthe rise of the idea of chronic homelessness and information management, etc. Discuss how the assumptions of the traditional approach doesnt hold up; that people cant overcome chronic conditions first (by their very nature and definition this is a flawed idea). Talk about the trauma that people experience, and their inability to care for themselves, loss of relationships, often within the context of depleted social networkscumulative disadvantagewhich will be important later in how we work with people.HomelessEmergency Shelter PlacementTransitional housingPermanent housingDirect access to permanent housing with supportsClient Choice

Housing First ModelRecovery Oriented Support and Treatment Services10105 Dimensions of a Pathways Housing First Program FidelityConsumer Choice Services Match Client Needs Recovery Oriented Services Separation of Housing and ServicesProgram Structure 1111Why focus on the chronically homeless?Existing systems repeatedly fail to engage/serve this groupSmall % overwhelms systems (10% 50%)Well known to the communityConsensus among multiple stakeholdersOpportunity to improve the overall system

12

Pine Street Inn, Boston

Lydia Downey from Managing to Ending homelessness 13Shelter utilization and capacity lets do the mathShelter of 100 beds = 36,500 bed nights

Average stay per guest:3 nights x 50 people = 150 bed nights180 nights x 5 people =900 bed nights

3 nights per guest = 12, 168 guests/year180 nights per guest= 202 guests/year

14Immediate Access to Housing and Appropriate Supports Elements of the Paradigm Shift

15Housing First Requires ChangeChange in view of those servedChange in goals of the systemChange in power relationshipsChange in locus of careChange in treatment cultureChange in funding patterns

16

ProgramsStages of Change

17Immediate Access to Housing and Appropriate Supports Elements of the Paradigm Shift

18Housing First Requires ChangeChange in view of those servedChange in goals of the systemChange in power relationshipsChange in locus of careChange in treatment cultureChange in funding patterns

19

ProgramsStages of Change

20HUD Continuum of Care Encouraging Housing FirstExtent to which PSH programs within a Community implement a Housing First approach

Prioritization of chronic homelessnessHousing offered without preconditionsRapid placement (and stabilization) in permanent housing with supports

21Current SystemCentralized Assessment and Centralized EntryHousingSt supportHousingModsupportHousingHighsupportshelterstreet

22

Pine Street Inn, Boston

Lydia Downey from Managing to Ending homelessness 23Shelter utilization and capacity lets do the mathShelter of 100 beds = 36,500 bed nights

Average stay per guest:3 nights x 50 people = 150 bed nights180 nights x 5 people =900 bed nights

3 nights per guest = 12, 168 guests/year180 nights per guest= 202 guests/year

24Steps needed to Introduce System Change Intervention Target Population: Community sets priority among homeless population Collaboration: Partnership among agencies (identification, data sharing, resource sharing, etc.)Operations: Design or re-design system so there is a clear map for all providers and participants Measure: Set specific targets and timelines and trach outcomes as a community (transparency)Leadership/Collaboration model

255 Dimensions of a Pathways Housing First Program FidelityConsumer Choice Services Match Client Needs Separation of Housing and ServicesRecovery Oriented Services Program structure

2626Choice in Housing (Pragmatic and Context Bound) Choice in availability (social & rental)

Match client choice and availability

Tenants agreements

Affordable & decent

Integrated into the community

Permanent

27200 Tenants, 200 Apartments, 2 Counties, 6 Cities,95 Landlords:

Housing Retention Rate 90.5% (12 mo)

Pathways Vermont, Housing First in Rural Settings

28Rental HousingCommunity Landlords as PartnersGuaranteed rent

Support for tenancy

No vacancy loss

Program responsible for damages

Recognition for help in solving problems

All have common goal: safe, decent, well-managed housing

29Housing First; Providing HousingHOUSING FIRST provides immediate access to housing

Programs find ways to engage private market or landlords or social housing

Rent or rent supplements are essential

Best practice target: provide access between 2-4 weeks from date of admission

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1b. Choice and SERVICES NO WRONG DOOR SpiritualEMPLOYMENTArts /Creativity HOUSING AddictionTxSOCIALSUPPPORT Documents/LegalEducationMentalHealthFriends & FamilySELF-DETERMINATION IS THE FOUNDATION OF PROGRAM PHILOSOPHYHEALTHCLIENT

Discuss service choices

2. MATCHING SERVICE NEEDS Community based, responsive, and flexibleHigh NeedACT - a multidisciplinary team and provides support and services directlyCaseload 1 to 10Work as Team Services provided in the participants home or community (group meetings offered at offices or other community settings)Off site and on-call services 7-24

Moderate NeedICM - case management team provides support and brokers services

Case loads of 1 to 15/20

FACT Team provides blended model

All teams use a recovery orientation

3232Discuss the historical piece and how in this intervention we are doing a blend of services . Case mangement plus, ACT lite, many sites are augmenting servicesLimits to Choice:SERVICESHome visits are mandatory and frequency may be increased to meet new circumstances

Planning for crises (WRAP plan) anticipates problems and provides a mutually agreed upon blueprint for response (e.g., medical, emotional, relapse, may include additional support, or hospitalization)

333. Separation of Housingand ServicesSeparated spatially, conceptually, and operationally

34PRINCIPLE 3: HOUSING and SERVICES ARE SEAPARATE DOMAINS

35Another Dimension of the Paradigm Shift is the Treatment Philosophy 4. Recovery Oriented Services

36System Change Question Can we simply introduce a new program into an existing system and keep everything else the same?

37Treatment Philosophy What Are Recovery Focused Services?What is a welcoming culture?What is trauma informed and trauma competent?Why use Harm Reduction?

38Housing First Services RequiresChange in Orientation and PracticeChange in

view of those served

goals of the system (maintenance to rehabilitation)

power relationships (shared decision making)

focus and locus of care

treatment culture

39

Harm Reduction andHousing First

Harm Reduction in Everyday Life 40

Harm Reduction is not limited to working with addictionSeek to reduce the risks associated with any harmful behaviors (safe injection, psychiatric symptoms, eviction, explotation, etc.)HR allows for consumer directed servicesAllows for honest discourse HR involves tolerance of risk by staff and agency

Harm Reduction and Housing First

Harm reduction is another part of the Housing First service philosophy. The Harm Reduction Coalition defines harm reduction as: A perspective and a set of practical strategies to reduce the negative consequences of drug use (food, relationships, finances), incorporating a spectrum of strategies from safer use to abstinence. Exampes of harm reduction include: - Condom use- Change patterns of use (amount, timing, location)- Superficial cutting vs. jabbing knife into leg- Needle exchange- Methadone (substitution therapy)

Historical Approaches to Alcohol/Drug Treatment

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Harm Reductions A perspective on treatment that includes a set of practical strategies to reduce the negative consequences of drug use (food, relationships, finances), that incorporates a spectrum of strategies from safer use to abstinence.

-The Harm Reduction Coalition

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Narrative TherapyLanguage does not simply reflect reality it constructs realitye.g., Addicts vs people who use substances

Naming the problem and locating the problem outside the personAllows us to unite with the person against the problem

Michael White and David EpstonAt Home/Chez Soi: Brian Williams and Barbara Baumgarten (2013)

44

Meet people where they are

Understanding why they use

Understand under which conditions are they more prone to use

Relapse plans = expected part of recovery

Strengths based- gains rather than losses approach - noting time reduction or abstinence is maintained

Principles of Harm Reduction - Intervention

**** targeted behavior45

46

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Examples of Reducing Risks

Using a screen or rubber tubing forcrack use

Getting off the bus two stops earlier and walking

Switching timing

Paying rent before buying substances

Buying a pint or 6 pack instead of aquart

Buy loosie instead of a pack

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Attitude is not everything, it is nearly everything Bert Pepper, MD

Harm Reduction and Housing First

Harm reduction is:An integral part of Housing First Rooted in unconditional positive regard for the individualSocial justice basedHousing is a basic human right.

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Decisional Balance: Having open and honest conversation

OptionBenefitsCostsMaking Change(reducing alcohol)Family would trust me againMore moneyBetter healthWont have a way to relaxLose my friendsLife will be boringNot ChangingHelps me relaxI Feel like I fit inLove the buzz I getLess moneyCannot see my kidsLegal problems

What are the costs and benefits of changing vs. not changing behavior?50

Home visit provides opportunity for observation of entire life space

Home Visits: Up Close and Personal

Observe and possibility to intervene in areas of health, mental health, self care, hygiene, social life, nutrition, community participation and more

What is the most respectful, empowering, and effective way to address the issues we observe? (stage of change is issue specific not person specific**)

51

Housing First and Harm ReductionMeet people where they are

but dont leave them there.

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- Staff and Agency orientation- Inter-personal (you are an active agent in the treatment and outcome) Recovery Orientation

53World Health Organization (WHO)Studies on Outcomes for Severe Mental Illness Outcomes at two years and five years, the patients in the developing countries had a considerably better course and outcome.

Report concludes being in a developed country was a strong predictor of not attaining a complete remission.

They also found that an exceptionally good social outcome characterized the patients in developing countries.

Source: Jablensky, A. Schizophrenia, manifestations, incidence and course in different cultures. Psychological Medicine 20, monograph(1992):1-95.

54WHO Studies (continued)Medication usage (Robert Whitaker: Mad in America, 2002.)

16% of patients in the developing countries were regularly maintained on antipsychotics61% of the patients in wealthier countries.

15-year to 20-year follow-up:53% of schizophrenia patients had favorable outcomes, were never psychotic after first 2 years, and of those 73% were employed.

Source: Harrison et al., in Schizophrenia Bulletin June 2001.

55Recovery, Homelessness, and Stages of Change Recovery is a personal journey of healing and transformationIt is reclaiming a full life in the community despite the experience of psychiatric disability and substance use issuesRecovery is an on-going process, takes time, and is multi-dimensional (and there are bumps along the way)Ending homelessness can be immediate recovery takes time

56Lifes domains develop at different paceLiving situation EmploymentIntimate RelationshipHealth/WellnessSocial supportsLeisure/recreation EducationSpirituality

57Recovery and Peer SupportWhat helps?What hinders? No substitute for peer support We need to expand definition of services

Summarize and emphasize the idea of where the locus of control is.. That is now with the client.. Give a hint about why MI works well with this perspective58Graduation and Recovery: Social Networks, Life Not Defined by Illness, Community Integration

59Social Inclusion and Community Integration

Promoting Social InclusionTerm Social Inclusion originated in EuropeSociety and its institutions actively promote opportunities for the participation of excluded persons including persons with psychiatric disabilities, in mainstream social, economic, educational, recreational, and cultural resources.

Full recovery can only occur when people with mental illnesses have the means and access to full-fledged membership in their communities (Thompson and Rowe, Psych Services, August 2010).

Next Up.Program Fidelity Break

62Pathways Housing First ProgramWhat is Program Fidelity? How do you Measure it?Why does it matter?

https://samhsa.gov/nationalregistry

63Why Fidelity?

64Components of Program FidelityAssess the extent to which components of the program model are being implemented

Structural features: what does the housing look like? What services are provided?Philosophy, values: participant choice? Harm reduction?

65Pathways Housing First Fidelity Scale Results: Program SpectrumThe case of Housing FirstIts all about Housing & ChoiceParticipants can choose to be clean and sober and theyll get an apartment. Or they can choose to continue using and well still give them housing in a room & board Participants can choose the housing they want regardless of whether they are actively using.

66Why Fidelity?Housing First is not Housing OnlyHousing First is not Housing is the first thing after theyChoice is not laissez-faireAssertive engagement is not coercionPeer Specialists are not junior case managers

Understand current practice & make improvementsMaximize outcomes

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Housing First:

Fidelity Scale DevelopmentStefancic, A., et al., in the American Journal of Psychiatric Rehabilitation (Special Issue on Pathways Housing First), December, 2013.

68Multiple Uses of FidelityFidelity: determine the degree to which the key components of the Housing First model are being implementedProgram DevelopmentGuide programs in implementing and operating the model?Targeted Technical AssistanceWhat specific areas does a program need to improve?Research/Program OutcomesHow are program components linked to outcomes?

Further understanding what the program is doing and looking at important outcomes, such as consumer goals and whether they are being met. 69Housing First: Hi-Fidelity

Few programs achieve perfect scores

Removing Essential Components

Pathways Housing First Fidelity Dimensions5 Domains:

1) Housing Choice & Structure2) Separation of Housing & Treatment3) Service Philosophy4) Service Array (Match Needs)5) Program Structure

73Sample ItemsRights of Tenancy, affordability, integrationNo housing readiness requirementsNo treatment contingencies: Can keep housing as long as participant follows a standard leaseExtent of implementation of harm reductionAvailability of services for assistance with psychiatric, substance abuse, employment/educational, and social integration needs

74Pathways Housing First Program EffectivenssIs it Effective?How Do you Measure Effectiveness?

75Fidelity Self-Assessment Survey & Residential Outcomes for California Full Service Partnerships 93 programs6,584 participantsDiagnosis Schizophrenia 62%Housing Outcomes 1 year pre- and post-enrollment into housing & services

76FSP Fidelity & OutcomesHigh fidelity programs: Better targeting - Enrolled consumers with much longer histories of homelessness (High = 101, Low = 46) and higher rates of substance abuseDays living independently in an apartment or SRO increased among high fidelity programs, but declined among low fidelity programs

UCSD: Gilmer et al., Psychiatric Services, 2014

77Fidelity Self-Assessment Survey & Residential OutcomesCalifornia FSPs:93 programs6,584 participantsSchizophrenia: 62%Bipolar Disorder: 22%Major Depression: 16%Substance Abuse Disorder: 50%Administrative DataOne year pre-post FSP enrollmentResidential Outcomes (days spent in living situation)(Todd Gilmer, UCSD, Archives Gen Psych. 2010)

Further understanding what the program is doing and looking at important outcomes, such as consumer goals and whether they are being met. Housing First Self-Assessment Survey:Overall Fidelity & Residential OutcomesHigh Fidelity programs: Enrolled consumers with much longer histories of homelessnessHigh = 101 daysLow = 46 daysDeclines in homelessness were greater among high fidelity programs. (p = .039)Days living independently in an apartment or SRO increased among high fidelity programs, but declined among low fidelity programs (p